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Anciano V, Barcel A, Kaiser P, Habet N, Wang S, Duemmler M, Edwards C, Irwin TA, Jones C. Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model. Foot Ankle Int 2024; 45:888-895. [PMID: 38853769 DOI: 10.1177/10711007241251816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
BACKGROUND Operative management of midfoot Charcot arthropathy often involves an extended midfoot arthrodesis with intramedullary bolts for fixation, a method called "beaming." Recently intramedullary nails have been introduced for the same indication, presumably providing stronger fixation. This study compares midfoot fusion nails to bolts with regard to stiffness and compressive ability. Additionally, we assessed how the addition of a subtalar fusion affects the construct. METHODS Medial column fusions were performed on 10 matched cadaver foot specimens with either a midfoot fusion nail or bolt. Specimens underwent cyclical compression loading, and displacement was measured. Separately, compressive forces produced were compared between the 2 fixation constructs using a synthetic bone block model. Lastly, another 10 matched specimens with midfoot fusion nails were evaluated with or without subtalar fusions. RESULTS No differences in stiffness were found in comparing matched specimens between nail vs bolt or comparing nail only without subtalar fusion (STF) vs nail with STF. The compressive force produced by the nail specimens was significantly and substantially greater than the bolted specimens (751.7 vs 139.0 N, P = .01). The accumulated height drop at the midfoot after cycling was 0.5 mm more in the nail group than in the bolt group (1.72 vs 1.22 mm, P = .008). The nail with STF group had greater initial height drop at the midfoot than the nail-only group (0.68 vs 0.34 mm, P = .035) with similar initial height drop at the ankle. However, there were no differences in strength among the matched pairs of midfoot nail-only vs midfoot nail with STF as measured by displacement after fatigue or maximum force at load to failure. CONCLUSION The overall cadaveric comparisons between matched pairs of nails vs bolts, and nail-only vs nail with STF, did not provide noteworthy differences between the groups with regard to strength or stiffness. However, the compressive force of the midfoot fusion nail was far superior to the bolt in a synthetic bone model. These data provide valuable insight comparing implants used in Charcot midfoot arthrodesis.
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Affiliation(s)
- Victor Anciano
- University of Louisville Health-Orthopedics, Louisville, KY, USA
| | - Anthony Barcel
- Carolina Orthopaedic and Neurosurgical Associates, Spartanburg, SC, USA
| | - Philip Kaiser
- California Pacific Orthopaedics and Sports Medicine, San Francisco, CA, USA
| | - Nahir Habet
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Marc Duemmler
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Campbell Edwards
- University of Louisville School of Medicine, Louisville, KY, USA
| | - Todd A Irwin
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
| | - Carroll Jones
- OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
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Skinner WC, Pattisapu N, Yeoh J, Grear BJ, Richardson DR, Murphy GA, Bettin CC. Surgical Outcomes in Charcot Arthropathy. Orthop Clin North Am 2024; 55:393-401. [PMID: 38782510 DOI: 10.1016/j.ocl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the mainstay of treatment, but surgical intervention has gained interest to improve poor long-term outcomes. A review of existing data on the operative management of CN demonstrates the potential benefits but also the continued risks associated with treatment. Additionally, a retrospective review of cohorts managed with limited surgical interventions (wound debridements, exostectomies, and other surgical procedures) compared to reconstructive procedures provides additional insight into the surgical management of CN.
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Affiliation(s)
- William C Skinner
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Naveen Pattisapu
- Beth Israel Lahey Hospital, 41 Mall Road, Burlington, MA 01805, USA
| | - Jane Yeoh
- Nanaimo Orthopaedics, 201-1515 Dufferin Crescent, Nanaimo, British Columbia V9S5H6, Canada
| | - Benjamin J Grear
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - David R Richardson
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Garnett A Murphy
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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Roberts RHR, Davies-Jones GR, Brock J, Satheesh V, Robertson GAJ. Surgical management of the diabetic foot: The current evidence. World J Orthop 2024; 15:404-417. [PMID: 38835689 PMCID: PMC11145970 DOI: 10.5312/wjo.v15.i5.404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/12/2024] [Accepted: 04/24/2024] [Indexed: 05/15/2024] Open
Abstract
The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.
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Affiliation(s)
| | - Gareth Rhys Davies-Jones
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
| | - James Brock
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Vaishnav Satheesh
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
| | - Greg AJ Robertson
- Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
- Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
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Mateen S, Thomas MA, Jappar A, Meyr AJ, Siddiqui NA. Minor and Major Amputation Rates Following Midfoot Charcot Reconstructive Surgery. J Foot Ankle Surg 2023; 62:977-980. [PMID: 37524241 DOI: 10.1053/j.jfas.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/04/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
Charcot neuroarthropathy (CNA) is a progressive disease that affects the bones and joints of the foot. To prevent collapse and loss of stability within the pedal architecture, CNA should be diagnosed and managed early. The objective of this retrospective study was to review patients who underwent midfoot CNA reconstructive surgery and evaluate subsequent rates of minor and major amputations. Secondary objectives include identifying patients that underwent midfoot CAN with and without a subtalar joint (STJ) arthrodesis. Out of the 72 patients, 4 (5.6%) underwent minor (digital, ray) amputation, 2 (2.8%) underwent proximal amputations (either below or above the knee), and none underwent midfoot amputation (transmetatarsal, Lisfranc, Chopart). A Fisher's exact test was employed to compare the outcomes of minor and major amputation rates in our CNA cohort with those who underwent midfoot CNA reconstruction with STJ arthrodesis and found no statistical significance (p = .15). Overall, a total progression to amputation was 8.4% following midfoot CNA reconstruction, with 2.8% of patients undergoing major amputation (below knee or above knee). Despite no statistical significance, we recommend surgeons to consider including an STJ arthrodesis in addition to midfoot CNA reconstruction to establish a stable and plantigrade foot.
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Affiliation(s)
- Sara Mateen
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Michael A Thomas
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, MD
| | - Asma Jappar
- Veterans Affairs Maryland Health Care System, Baltimore, MD
| | - Andrew J Meyr
- Department of Podiatric Surgery, Temple University School of Podiatric Medicine and Temple University Hospital, Philadelphia, PA
| | - Noman A Siddiqui
- Director, Podiatric Surgery, International Center for Limb Lengthening, Baltimore, MD; Director, Foot and Ankle Deformity Correction and Orthoplastics Fellowship, Baltimore, MD; Chief of Podiatry, Sinai and Northwest Hospitals, Baltimore, MD.
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High rate of complications after corrective midfoot/subtalar arthrodesis and Achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3. INTERNATIONAL ORTHOPAEDICS 2023; 47:141-150. [PMID: 36136106 PMCID: PMC9810683 DOI: 10.1007/s00264-022-05567-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Corrective midfoot resection arthrodesis is the standard treatment of Charcot arthropathy type Sanders 2 and 3 with severe dislocation. In order to critically evaluate the effect of surgical correction, a retrospective analysis of our patient cohort was performed. Hereby, special emphasis was set on the analysis of the pre- and post-operative equinus position of the hindfoot. METHODS Retrospectively, all patients (n = 82) after midfoot resection arthrodesis in Charcot type Sanders 2 or 3 were included. Complications were recorded, and the mean complication-free interval was calculated. Additionally, the calcaneal pitch as well as Meary's angle were measured pre- and post-operatively and in case of complications. RESULTS Overall complication rate was 89%. Revision surgery was necessary in 46% of all patients. The mean complication-free interval was 285 days (0-1560 days). Calcaneal pitch and Meary's angle significantly improved after operation but returned to pre-operative values after onset of complications. Achilles tendon lengthening showed no significant effects on the mean complication-free interval. CONCLUSION Operative treatment of Charcot arthropathy remains a surgical challenge with high complication rates. Surgical correction of equinus position has been highlighted for successful treatment but was not able to prevent complications in this study, which is demonstrated by the recurrent decrease of the calcaneal pitch in cases of reoperation. Therefore, as a conclusion of our results, our treatment algorithm changed towards primarily addressing the equinus malpositioning of the hindfoot by corrective arthrodesis of the hindfoot.
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Beals CJ, Wong GAS, Dupont KM, Safranski DL. Effect of Simulated Bone Resorption on the Biomechanical Performance of Intramedullary Devices for Foot and Ankle Arthrodesis. J Foot Ankle Surg 2022; 62:7-13. [PMID: 35370055 DOI: 10.1053/j.jfas.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 02/03/2023]
Abstract
Midfoot and subtalar arthrodesis surgeries are performed to correct foot deformities and relieve arthritic pain. These procedures often employ intramedullary (IM) devices. The aim of the present study was to evaluate the biomechanical performance of a sustained dynamic compression (SDC) IM device compared to mechanically static devices in withstanding the effects of simulated bone resorption. Mechanically static and SDC IM devices were implanted in simulated bone blocks (n = 5/device). Compressive loads were measured with a custom-made mechanism to simulate bone resorption. The construct bending stiffness was determined from a 4-point bend test. Resorption was simulated by cutting a 1 mm or 2 mm gap in the midpoint of each construct and repeating the loading (n = 6/device). Initial compressive loads after device insertion were greater in the SDC IM devices when compared to the static devices (p < .01). The SDC device was able to sustain compression from 2 mm to 5.5 mm of simulated resorption depending upon device length, while the static devices lost compression within 1 mm of simulated resorption regardless of implant length (p < .001). In the 4-point bend test, the SDC device maintained its bending stiffness during simulated resorption whereas the static device displayed a significant loss in bending stiffness after 1 mm of simulated resorption (p < .001). The SDC device exhibited a significantly higher bending stiffness than the static device (p < .001). The SDC IM device demonstrated superior biomechanical performance during simulated resorption compared to static devices (p < .001). In conclusion, the ability of SDC IM devices to maintain construct stability and sustain compression across the fusion site while adapting to bone resorption may lead to greater fusion rates and overall quicker times to fusion than static IM devices. Surgeons who perform midfoot and subtalar arthrodesis procedures should be aware of a device's ability to sustain compression, especially in cases where bone resorption and joint settling are prevalent postoperatively.
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Affiliation(s)
- Caitlyn J Beals
- Engineering Student, Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Gabriella A S Wong
- Engineering Student, Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA
| | | | - David L Safranski
- Research Leader, Clinical Affairs, Foot & Ankle, Atlanta, GA; School of Materials Science and Engineering, Georgia Institute of Technology, Atlanta, GA.
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Wukich DK, Liu GT, Johnson MJ, Van Pelt MD, Raspovic KM, Lalli T, Nakonezny P. A Systematic Review of Intramedullary Fixation in Midfoot Charcot Neuroarthropathy. J Foot Ankle Surg 2022; 61:1334-1340. [PMID: 35701302 DOI: 10.1053/j.jfas.2022.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/09/2020] [Accepted: 04/20/2022] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy can cause severe deformity of the midfoot, and intramedullary use of beams and bolts has been utilized as a method of definitive stabilization. This systematic review evaluated the outcomes of intramedullary beaming in patients with Charcot neuroarthropathy and determined the methodological quality of the studies. Four online databases were searched: PubMed, MEDLINE (Clarivate Analytics), CINAHL (Cumulative Index to Nursing and Allied Health) and Web of Science (Clarivate Analytics). To assess the methodological quality of the studies, the Coleman Methodology Score was used. The data was pooled into 2 outcomes groups for comparison: (1) Studies that reported on the outcomes of Charcot specific implants (study group). (2) Studies that reported on the outcomes using non-Charcot specific implants (control group). After screening, 16 studies were included. Compared to our control group, our study group had significantly higher rates of overall hardware complications, hardware migration, surgical site infection, reoperation, and nonunion. The study group had significantly lower rates of limb salvage compared to the control group. Our study and control groups did not differ in the rates of hardware breakage, wound healing complications, or mortality. The limb salvage rate was 92% and 97% of patients were still alive at a mean follow-up of 25 months. The mean Coleman Methodology Score indicated the quality of the studies was poor and consistent with methodologic limitations. The quality of published studies on intramedullary implants for Charcot reconstruction is low. Complications when utilizing intramedullary fixation for Charcot reconstruction are high, whether or not Charcot specific implants are used.
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Affiliation(s)
- Dane K Wukich
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - George T Liu
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew J Johnson
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael D Van Pelt
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine M Raspovic
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Trapper Lalli
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Paul Nakonezny
- Department of Clinical Sciences (Biostatistics), University of Texas Southwestern Medical Center, Dallas, TX
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Casciato DJ, Stone R, Thompson J, Venero M, Chiu M, Blum J, Barron I, Hyer C. Radiodensity Analysis of Medial Column Superconstruct Fixation Sites in Midfoot Charcot Neuroarthropathy. J Foot Ankle Surg 2022; 61:1076-1080. [PMID: 35181205 DOI: 10.1053/j.jfas.2022.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/06/2021] [Accepted: 01/11/2022] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy (CN) is a highly destructive, pathologic process with devastating consequences to foot structure and viability. The use of intramedullary fixation "superconstructs" allows for "re-bar" support of compromised bone and allows for some dynamic fixation. This study examines radiodensity in Hounsfield units (HU) to compare bone quality of medial column fixation targets using computed tomography scans between patients with and without midfoot CN. A retrospective chart review identified control (nondiabetic, non-CN; n = 29) and midfoot CN (n = 21) groups. Patient demographics and medical history were collected. Two reviewers measured the mean HU of a circular region of interest centered on the first metatarsal head and the anterior, middle, and posterior thirds of the talar body. Radiodensity was compared between groups, and among talar locations, Eichenholtz stages and Brodsky types, with statistical significance set at p ≤ .05. Age and body mass index were not significantly different between groups. The CN group maintained greater mean HU than the control group at the metatarsal head (p < .001), and talar body locations (p < .019). The difference in mean HU of these bones was not statistically significant between Stages 0 to 1 and Stages 2 to 3 or Brodsky Types 1 and 2. Mean HU differences among talus positions were not statistically significant. Indirect bone density analysis using HU showed an increased density in CN patients with no significant difference among talar body locations or midfoot Charcot stages and types. These results may assist in optimizing fixation length. Future studies may examine these densities in ankle CN.
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Affiliation(s)
| | - Ryan Stone
- Resident Physician, OhioHealth Grant Medical Center, Columbus, OH
| | - John Thompson
- Resident Physician, OhioHealth Grant Medical Center, Columbus, OH
| | - Marissa Venero
- Resident Physician, Orlando VA Medical Center, Orlando, FL
| | - Michael Chiu
- Resident Physician, Orlando VA Medical Center, Orlando, FL
| | - Jonathan Blum
- Site Director, University of Central Florida College of Medicine, Orlando, FL
| | - Ian Barron
- Teaching Faculty, OhioHealth Grant Medical Center, Columbus, OH
| | - Christopher Hyer
- Fellowship Co-Director, Orthopedic Foot and Ankle Center, Worthington, OH
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DuBois KS, Cates NK, O'Hara NN, Lamm BM, Wynes J. Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy. J Foot Ankle Surg 2022; 61:1039-1045. [PMID: 35221218 DOI: 10.1053/j.jfas.2022.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.
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Affiliation(s)
- Korey S DuBois
- Limb Preservation and Deformity Correction Fellow, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD.
| | - Nicole K Cates
- Fellowship Trained Foot and Ankle Surgeon, Hand & Microsurgery Medical Group, San Francisco, CA
| | - Nathan N O'Hara
- Research Associate, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley M Lamm
- Chief, Foot and Ankle Surgery at St. Mary's Medical Center and the Palm Beach Children's Hospital, West Palm Beach, FL
| | - Jacob Wynes
- Assistant Professor, Fellowship Program Director, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
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Gratwohl V, Jentzsch T, Schöni M, Kaiser D, Berli MC, Böni T, Waibel FWA. Long-term follow-up of conservative treatment of Charcot feet. Arch Orthop Trauma Surg 2022; 142:2553-2566. [PMID: 33829302 PMCID: PMC9474498 DOI: 10.1007/s00402-021-03881-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 03/24/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN. METHODS A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development. RESULTS Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations. CONCLUSIONS With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking. LEVEL OF EVIDENCE III, long-term retrospective cohort study.
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Affiliation(s)
- Viviane Gratwohl
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Thorsten Jentzsch
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Madlaina Schöni
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Dominik Kaiser
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Martin C. Berli
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Thomas Böni
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
| | - Felix W. A. Waibel
- grid.412373.00000 0004 0518 9682Divisions of “Prosthetics and Orthotics” and “Foot and Ankle Surgery”, Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008 Zürich, Switzerland
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Wukich DK, Liu GT, Raspovic K, Vicenzi F. Biomechanical Performance of Charcot-Specific Implants. J Foot Ankle Surg 2021; 60:440-447. [PMID: 33612405 DOI: 10.1053/j.jfas.2020.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/30/2020] [Indexed: 02/03/2023]
Abstract
Over the past 2 decades, an increased number of diabetic Charcot neuroarthropathy reconstructions have been performed. Despite advances in implant technology, arthrodesis complication rates remain high. This study examined the biomechanical properties (4-point bending, cantilever bending, and thread pullout resistance) of intramedullary implants designed for midfoot reconstruction. Large implants included A1 (7.4 mm cannulated stainless steel beam), B1 (6.5 mm solid titanium bolt), and C1 (7.0 mm cannulated titanium beam). Smaller implants included A2 (5.4 mm cannulated stainless steel beam) and C2 (5.0 mm solid titanium bolt). Four-point bending testing compared flexural properties of the body of the implants. Cantilever-bending testing was performed with the maximum bending moment being applied off the main thread of the implant to assess the thread portion. Thread pullout strength was tested by fixing the implants to a Sawbone block on a platform, and the distal portion of the implant in a clamp connected to loading actuator. Implant A1 demonstrated higher stiffness, force to failure, and fatigue compared to implants B1 and C1 (p < .05). Pullout strength of implant A1 was higher than implant B1 (p < .05). Thread fatigue strength of implant A1 was higher than implant C1 (p < .05). Implant A2 demonstrated higher stiffness, force to failure, tip fatigue strength, and thread pullout strength compared to implant C2 (p < .05), while implant C2 demonstrated higher body fatigue failure than implant A2 (p < .05). Alteration of beam/bolt parameters influences the biomechanical performance of implants used in Charcot reconstruction. Greater stiffness resists deformation, providing improved stability. Greater static failure load and fatigue limit improves the implant's ability to withstand higher and repetitive loads before failing This study should stimulate further clinical research to determine if these biomechanical properties translate into reduced implant failure rates and improved clinical outcomes in patients with diabetic Charcot neuroarthropathy.
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Affiliation(s)
- Dane K Wukich
- Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
| | - George T Liu
- Associate Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Katherine Raspovic
- Assistant Professor, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Federico Vicenzi
- Engineer, Department of Research, Development and Innovation, Orthofix Srl, Bussolengo, Italy
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12
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Ahluwalia R, Maffulli N, Lázaro-Martínez JL, Kirketerp-Møller K, Reichert I. Diabetic foot off loading and ulcer remission: Exploring surgical off-loading. Surgeon 2021; 19:e526-e535. [PMID: 33642205 DOI: 10.1016/j.surge.2021.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/26/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration. METHODS We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations. RESULTS Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements. CONCLUSIONS AND IMPLICATIONS Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.
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Affiliation(s)
- Raju Ahluwalia
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England, E1 4DG, UK.
| | - José L Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Del Hospital, Clínico San Carlos (IdISSC), 28040, Madrid, Spain.
| | - Klaus Kirketerp-Møller
- Copenhagen Wound Healing Center, Department of Dermatology and Wounds, Bispebjerg Hospital, Copenhagen, Denmark; Steno Diabetes Center Copenhagen, Denmark.
| | - Ines Reichert
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
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13
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Wang G, Lin J, Zhang H, Pei Y, Zhu L, Xu Q. Three-dimension correction of Charcot ankle deformity with a titanium implant. Comput Assist Surg (Abingdon) 2021; 26:15-21. [PMID: 33625935 DOI: 10.1080/24699322.2021.1887356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy of the ankle is an extremely challenging clinical dilemma, and its surgical management can be highly complicated. The goal of Charcot ankle treatment is to to restore a plantigrade and stable foot, and thus to avoid ulceration with subsequent infection. This report aims to introduce a method of correcting ankle deformity using a novel 3D printing technique. PATIENT AND METHODS One patient with Charcot ankle deformity was operated in this study. The ankle deformity of this patient was quantified in three dimensions through computed tomography. On the basis of the computed tomography scans, a new titanium implant was designed and manufactured using 3D printing. The implant was applied in the surgery of tibio-talo-calcaneal arthrodesis to restore local anatomy of the affected ankle of the patient with Charcot neuroarthropathy. RESULTS Evaluation of the post-operative radiography indicated union in the affected ankle. After surgery, the planar foot in this patient was restored. The patient was satisfied with the post-operative course, and joint fusion was successful as indicated by 2-year post-operative evaluation. The results of post-operative follow-up showed that the lower limb length of the patient with Charcot neuroarthropathy was salvaged, and the patient retained the plantigrade foot. CONCLUSION Three-dimensional printing technique combined with tibio-talo-calcaneal arthrodesis may help to correct ankle deformity in patients with Charcot neuroarthropathy.
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Affiliation(s)
- Gang Wang
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Junhao Lin
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Hong Zhang
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Yantao Pei
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Lei Zhu
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Qingjia Xu
- Department of Hand and Foot Surgery, Department of Orthropedics, Qilu Hospital of Shandong University, Jinan, P.R. China
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Frøkjær J. Surgical treatment of midfoot charcot neuroarthropathy review of literature and our results after superconstruct reconstruction of midfoot charcot neuroarthropathy. J Clin Orthop Trauma 2021; 17:59-64. [PMID: 33680840 PMCID: PMC7919936 DOI: 10.1016/j.jcot.2021.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Charcot neuroarthropathy (CN) of the midfoot was traditionally treated non-operatively with off-loading in a total contact cast (TCC). After introduction of the super construct concept, promising results were reported, however there is a need for further studies on this concept. Analysis of non-operative versus operative treatment is presented as well as our results from a consecutive series of 20 patients operated with the superconstruct concept. METHODS Twenty patients were operated from July 2017 until June 2020. Mean age was 58 years (50-80), mean weight was 116 kg (68-156), giving a BMI of 31 (26-45). Preoperative patients off-loaded in a TCC until decreased swelling and skin temperature measurement or ulcer had healed, mean 16 weeks immobilization. Surgery was without tourniquet, using a standard medial and lateral incision. Mean follow up is 24 (5-40) months. RESULTS Mean operation time was 227 (150-315) minutes. Medial column fusion was mandatory, in five cases as an isolated procedure, in 12 cases in combination with lateral column fusion and in three cases with a talocalcaneal fusion. Preoperative lateral Meary angle decreased from 23.5 to 9.6°, antero-posterior Meary angle decreased from 16.0 to 4.7°. Eight patients had postoperative incisional wound problems. Four patients had partial implant removal. All healed with a good clinical result. Two patients had an acute Charcot attack in the ankle joint during postoperative mobilization. One had a severe collapse of the talus resulting in a below knee amputation, giving an amputation rate of 5%. Radiographic examination at follow up, showed bone union of all patients. Nineteen patients are ambulated in orthopedic shoes at latest follow up, giving a 95% satisfactory result. CONCLUSION Superconstruct reconstruction of CN midfoot collapse is a safe procedure. There are incisional wound problems, recognition and fast treatment of these complications is important to achieve good results. There is a risk for overloading the ankle, initiating a new acute Charcot attack. Attention must be on this problem. The surgical technique is demanding and should be performed by experienced foot and ankle surgeons in a multidisciplinary team set up.
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15
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Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
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16
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Mehlhorn AT, Ugland KI, Hörterer H, Gottschalk O, Südkamp N, Walther M. A high-profile thread with grit-blasted and acid-etched surface reduces loosening of medial column fusion bolt in instable Charcot foot. Foot Ankle Surg 2020; 26:637-643. [PMID: 31521519 DOI: 10.1016/j.fas.2019.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/30/2019] [Accepted: 08/08/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intramedullary fusion bolts (FB) were introduced to stabilize the medial column of the instable Charcot foot (ICF), but complications as bolt loosening or breakage are frequent. We compared the use of a standard FB and a high-profile threaded FB with a grit-blasted surface. We hypothesized that implant related complications occurred less often and osseous consolidation of fusion sites was more distinctive using the latter type of FB. METHODS Consecutive patients suffering from an ICF were stabilized with a high-profile threaded and surface-modified FB (HTFB) (n=20) or with a standard FB (n=20) which was placed into the first ray. Additional bolts and dorsal low-profile plates were applied in every patient. In a retrospective assessment osseous consolidation of the fusion sites was analyzed at 3 month and quantified by CT scan. At 3 and 12 month longitudinal foot arch collapse and rate of bolt loosening were assessed. RESULTS Compared to the control group, the HTFB group reached significant higher consolidation after 3 month. No dislocation and a single bolt breakage was observed in the HTFB group after the fourth month, while the control group included 3 patients with bolt dislocation at 3±1 month and 5 patients with bolt breakage at 6±1.8 month. Compared to preoperative values, the improvement of Meary's angle after one-year was significant higher in the HTFB group (23.4°±14) than in controls (11.7°±13). CONCLUSIONS Modification of bolt design improves the stability of the medial column: A higher rate of osseous consolidation of the medial column leads to lower rate of bolt dislocation/breakage and finally to permanently erected longitudinal foot arch. Initially disappointing results following medial column stabilization with fusion bolts can be rejected by modifications of bolt design and its technical application.
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Affiliation(s)
- Alexander T Mehlhorn
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany; Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University of Freiburg, Medical Center, Freiburg, Germany.
| | - Karl I Ugland
- Department of Biosciences, University of Oslo, PB 1066 Blindern, 0316 Oslo, Norway
| | - Hubert Hörterer
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
| | - Oliver Gottschalk
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
| | - Norbert Südkamp
- Department of Orthopedics and Trauma Surgery, Albert-Ludwigs University of Freiburg, Medical Center, Freiburg, Germany
| | - Markus Walther
- Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
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17
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Cianni L, Bocchi MB, Vitiello R, Greco T, De Marco D, Masci G, Maccauro G, Pitocco D, Perisano C. Arthrodesis in the Charcot foot: a systematic review. Orthop Rev (Pavia) 2020; 12:8670. [PMID: 32913602 PMCID: PMC7459387 DOI: 10.4081/or.2020.8670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022] Open
Abstract
The Charcot foot is a condition characterized by a progressive derangement of the foot. The type of deformity and patient clinical conditions will lead to the proper surgical approach among exostectomy, arthrodesis (through external and/or internal fixation) and amputation. Many authors report good clinical outcomes performing the arthrodesis in Charcot foot; however, the choice of the most appropriate hardware is still an issue. The aim of this study is to analyze the outcomes of different hardware in midfoot and hindfoot Charcot arthrodesis.
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Affiliation(s)
- Luigi Cianni
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Maria Beatrice Bocchi
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Raffaele Vitiello
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Tommaso Greco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Davide De Marco
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Giulia Masci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome.,Università Cattolica del Sacro Cuore, Rome
| | - Dario Pitocco
- Diabetes Care Unit, Institute of Endocrinology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Perisano
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
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18
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Ramanujam CL, Stuto AC, Zgonis T. Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review. J Wound Care 2020; 29:S19-S28. [PMID: 32530758 DOI: 10.12968/jowc.2020.29.sup6.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes. METHOD A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded. RESULTS A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction. CONCLUSION Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
| | - Alan C Stuto
- LVPG Orthopedics and Sports Medicine, Lehigh Valley Health Network, Bethlehem, PA, US
| | - Thomas Zgonis
- Externship and Reconstructive Foot and Ankle Surgery Fellowship Programs, Division of Podiatric Medicine and Surgery, Department of Orthopaedics, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas, US
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Abstract
We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.
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Affiliation(s)
- Ashtin Doorgakant
- Foot and Ankle Unit, Northern General Hospital, Foot and Ankle Offices, Selby Wing, Herries Road, Sheffield S5 7AU, UK.
| | - Mark B Davies
- Northern General Hospital, Foot and Ankle Unit, Herries Road, Sheffield, S5 7AU, UK
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20
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Ha J, Hester T, Foley R, Reichert IL, Vas PR, Ahluwalia R, Kavarthapu V. Charcot foot reconstruction outcomes: A systematic review. J Clin Orthop Trauma 2020; 11:357-368. [PMID: 32405193 PMCID: PMC7211810 DOI: 10.1016/j.jcot.2020.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. METHODS We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. RESULTS A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. CONCLUSIONS Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.
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Affiliation(s)
- Joon Ha
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Thomas Hester
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Robert Foley
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Ines L.H. Reichert
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Prashanth R.J. Vas
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
- King’s Diabetic Foot Clinic, King’s College College Hospital, London
| | - Raju Ahluwalia
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
| | - Venu Kavarthapu
- Department of Orthopaedics, King’s College Hospital NHS Trust, London, United Kingdom
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Simonik MM, Wilczek J, LaPorta G, Willing R. Biomechanical Comparison of Intramedullary Beaming and Plantar Plating Methods for Stabilizing the Medial Column of the Foot: An In Vitro Study. J Foot Ankle Surg 2019; 57:1073-1079. [PMID: 30172718 DOI: 10.1053/j.jfas.2018.03.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy often results in a rocker-bottom foot deformity, which leads to ulceration, infection, and amputation. Surgical techniques to reconstruct the medial column include intramedullary beaming and plantar plating, with disagreement regarding which approach provides a stronger construct with superior stability and fixation. The objective of the present cadaveric study was to compare the construct rigidity and strength of beaming and plantar plating of the medial column of 5 paired bilateral feet. Cannulated titanium beams and plates were implanted in the right and left feet, respectively. The specimens underwent interval testing to generate load-displacement and load-strain curves, cyclic loading at low loads, and then were loaded to failure. The beamed and plated specimens had statistically similar stiffness (p = .80) with a mean of 11.1 ± 3.9 N/mm and 11.3 ± 5.9 N/mm, respectively. The beamed and plated specimens had a statistically similar mean strain of -164 ± 75.1 µε and -208 ± 87.8 µε on the dorsal (p = .45) and 92 ± 90.4 µε and 221 ± 100.5 µε on the plantar (p = .08) surfaces of the first metatarsal. Three beamed specimens failed from talus fracture (60%), and 2 beams plastically deformed (40%). Two plated specimens failed from talus fracture (40%), and 3 experienced screw pullout (60%). The beamed and plated specimens withstood a mean load to failure of 234 ± 111.4 N and 140 ± 68.9 N, respectively, with the difference statistically significant (p = .04). Overall, beaming was more robust than plantar plating, because it was less sensitive to specimen size and bone quality.
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Affiliation(s)
- Melissa M Simonik
- Doctoral Candidate, Department of Mechanical Engineering, Binghamton University, Binghamton, NY
| | - Jessica Wilczek
- Surgeon, Department of Graduate Medical Education and Podiatric Surgery, Our Lady of Lourdes Memorial Hospital, Binghamton, NY
| | - Guido LaPorta
- Surgeon, Department of Graduate Medical Education and Podiatric Surgery, Our Lady of Lourdes Memorial Hospital, Binghamton, NY
| | - Ryan Willing
- Assistant Professor, Department of Mechanical Engineering, Binghamton University, Binghamton, NY.
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Ford SE, Cohen BE, Davis WH, Jones CP. Clinical Outcomes and Complications of Midfoot Charcot Reconstruction With Intramedullary Beaming. Foot Ankle Int 2019; 40:18-23. [PMID: 30284492 DOI: 10.1177/1071100718799966] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: The purpose of this study was to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. METHODS: Consecutive patients with midfoot Charcot treated at a tertiary-care foot and ankle center from January 2013 to July 2016 who underwent corrective osteotomy with internal beam fixation were identified; 25 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, weightbearing radiographs, and patient-reported outcome measures. The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Median age was 58 years, median BMI was 32, and 80% were diabetic (75% insulin-dependent). RESULTS: An ulcer-free, stable, plantigrade foot was obtained in 84% of patients. The radiographic lateral and anteroposterior Meary angle medians improved 9° and 15°, respectively, from preoperative to final postoperative weightbearing measurements ( P < .001 and P = .02). Overall, 46% of midfoot osteotomies were united on final radiographs at a median 18-month radiographic follow-up. Deep infection developed in 6 (24%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (P = .04); all 6 deep infections occurred in patients with preoperative ulceration. Four (16%) patients progressed to amputation at a mean 15 postoperative months, all for deep infection. CONCLUSION: Midfoot Charcot reconstruction with intramedullary beaming allowed for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates were high, especially in patients with preoperative ulceration. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Affiliation(s)
- Samuel E Ford
- 1 Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Bruce E Cohen
- 2 OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
| | - W Hodges Davis
- 2 OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
| | - Carroll P Jones
- 2 OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA
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Shazadeh Safavi P, Jupiter DC, Panchbhavi V. A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot. J Foot Ankle Surg 2018; 56:1249-1252. [PMID: 28778632 DOI: 10.1053/j.jfas.2017.06.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 02/03/2023]
Abstract
Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.
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Affiliation(s)
| | - Daniel C Jupiter
- Assistant Professor, Preventative Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, TX
| | - Vinod Panchbhavi
- Professor of Orthopedic Surgery, Chief, Division of Foot & Ankle Surgery, and Director, Foot & Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch, Galveston TX
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Simons P, Sommerer T, Zderic I, Wahl D, Lenz M, Skulev H, Knobe M, Gueorguiev B, Richards RG, Klos K. Biomechanical investigation of two plating systems for medial column fusion in foot. PLoS One 2017; 12:e0172563. [PMID: 28222170 PMCID: PMC5319781 DOI: 10.1371/journal.pone.0172563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/07/2017] [Indexed: 01/30/2023] Open
Abstract
Background Arthrodesis of the medial column (navicular, cuneiform I and metatarsal I) is performed for reasons such as Charcot arthropathy, arthritis, posttraumatic reconstruction or severe pes planus. However, the complication rate is still high and mainly resulting from inadequate fixation. Special plates, designed for medial column arthrodesis, seem to offer potential to reduce the complication rate. The aim of this study was to investigate biomechanically plantar and dorsomedial fusion of the medial column using two new plating systems. Methods Eight matched pairs of human cadaveric lower legs were randomized in two groups and medial column fusion was performed using either plantar or dorsomedial variable-angle locking compression plates. The specimens were biomechanically tested under cyclic progressively increasing axial loading with physiological profile of each cycle. In addition to the machine data, mediolateral x-rays were taken every 250 cycles and motion tracking was performed to determine movements at the arthrodesis site. Statistical analysis of the parameters of interest was performed at a level of significance p = 0.05. Results Displacement of the talo-navicular joint after 1000, 2000 and 4000 cycles was significantly lower for plantar plating (p≤0.039) while there was significantly less movement in the naviculo-cuneiform I joint for dorsal plating post these cycle numbers (p<0.001). Displacements in all three joints of the medial column, as well as angular and torsional deformations between the navicular and metatarsal I increased significantly for each plating technique between 1000, 2000 and 4000 cycles (p≤0.021). The two plating systems did not differ significantly with regard to stiffness and cycles to failure (p≥0.171). Conclusion From biomechanical point of view, although dorsomedial plating showed less movement than plantar plating in the current setup under dynamic loading, there was no significant difference between the two plating systems with regard to stiffness and cycles to failure. Both tested techniques for dorsomedial and plantar plating appear to be applicable for arthrodesis of the medial column of the foot and other considerations, such as access morbidity, associated deformities or surgeon's preference, may also guide the choice of plating pattern. Further clinical studies are necessary before definitive recommendations can be given.
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Affiliation(s)
- Paul Simons
- Department of Foot and Ankle Surgery, Catholic Clinic Mainz, Mainz, Germany
| | | | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Dieter Wahl
- AO Research Institute Davos, Davos, Switzerland
| | - Mark Lenz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | | | - Matthias Knobe
- Department of Trauma and Reconstructive Surgery, University Hospital Aachen, Aachen, Germany
| | | | | | - Kajetan Klos
- Department of Foot and Ankle Surgery, Catholic Clinic Mainz, Mainz, Germany
- * E-mail:
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25
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An Overview of Internal and External Fixation Methods for the Diabetic Charcot Foot and Ankle. Clin Podiatr Med Surg 2017; 34:25-31. [PMID: 27865312 DOI: 10.1016/j.cpm.2016.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Diabetic Charcot neuroarthropathy (DCN) of the foot and ankle is a challenging disease with regard to clinical presentation, pathogenesis, and prognosis. Its surgical management is equally difficult to interpret based on the wide array of options available. In the presence of an ulceration or concomitant osteomyelitis, internal fixation by means of screws, plates, or intramedullary nailing needs to be avoided when feasible. External fixation becomes a great surgical tool when managing DCN with concomitant osteomyelitis. This article describes internal and external fixation methods along with available literature to enlighten surgeons faced with treating this complex condition.
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Alrashidi Y, Hügle T, Wiewiorski M, Herrera-Perez M, Valderrabano V. Surgical Treatment Options for the Diabetic Charcot Midfoot Deformity. Clin Podiatr Med Surg 2017; 34:43-51. [PMID: 27865314 DOI: 10.1016/j.cpm.2016.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Management of diabetic Charcot midfoot deformity is one of the most demanding aspects of foot and ankle surgery. Its treatment should aim at reducing the rate of complications, including foot and ankle amputations or limb loss. Attempting reconstruction at Eichenholtz stages I and II carries the risk of infection and loss of fixation. It is advisable to limit surgical reconstruction to Eichenholtz stage III in the absence of any evidence of infection or vascular insufficiency. Achilles lengthening or gastrocnemius-soleus release is an essential initial step in surgery. Addressing the medial foot column first is a key to a successful reconstruction.
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Affiliation(s)
- Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, PO Box 30001, Prince Naif Road, Almadinah Almunawwarah, Kingdom of Saudi Arabia; Orthopaedic Department, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 11-15, Basel 4010, Switzerland
| | - Thomas Hügle
- Rheumatology Department, Osteoarthritis Research Center Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 11-15, Basel 4010, Switzerland
| | - Martin Wiewiorski
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Winterthur, Brauerstrasse 15, Winterthur 8401, Switzerland
| | - Mario Herrera-Perez
- Universidad de La Laguna, University Hospital of Canary Islands, Calle El Pilar 50 4 piso, Tenerife 38002, Spain
| | - Victor Valderrabano
- Orthopaedic Department, Osteoarthritis Research Center Basel, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 11-15, Basel 4010, Switzerland.
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Mehlhorn AT, Walther M, Iblher N, Südkamp NP, Schmal H. Complication assessment and prevention strategies using midfoot fusion bolt for medial column stabilization in Charcot's osteoarthropathy. Foot (Edinb) 2016; 29:36-41. [PMID: 27888790 DOI: 10.1016/j.foot.2016.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/21/2016] [Accepted: 10/24/2016] [Indexed: 02/04/2023]
Abstract
In Charcot's osteoarthropathy stabilization of the medial column of the foot was introduced in order to establish a stable foot and reduce the risk for amputation. This study was performed to analyze postoperative complications, define risk factors for those and develop strategies for prevention. Since bolt dislocation takes place frequently, it was aimed to predict an appropriate time point for bolt removal under the condition that osseous healing has occurred. Fourteen consecutive patients with neuroosteoarthropathy of the foot and arch collapse were treated with open reduction and stabilization using midfoot fusion bolt and lateral lag screws. Age, gender, presence of preoperative osteomyelitis or ulcer, number of complications and operative revisions, Hba1c value, consolidation of arthrodesis, presence of a load-bearing foot and period to bolt dislocation was assessed. The mean follow-up was 21.4±14.6 (mean±SDM) months, 64% of patients suffered from diabetes with a preoperative Hba1c of 8.5±2.4. The mean number of revisions per foot was 3.6±4.1. Bolt dislocation was seen in 57% of the patients following 11.3±8.5 months; in 75% of these patients bony healing occurred before dislocation. There was a significant association between preoperative increased Hba1c value, presence of preoperative ulcer and wound infection. Healing of arthrodesis was demonstrated in 57% and a permanent weight-bearing foot without recurrent ulcer was achieved in 79%. The early and late postoperative complications could be controlled in general. A fully load-bearing and stable foot was obtained, despite osseous consolidation was not detected in all of these cases. Once a stable foot has established early removal of fusion bolt should be considered. To decrease the risk of infection Hba1c should be adjusted and ulcers should be treated before the operation.
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Affiliation(s)
- Alexander T Mehlhorn
- Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrasse 55, Germany; Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106 Freiburg, Germany; Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Harlachingerstraße 51, 81547 Munich, Germany.
| | - Markus Walther
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106 Freiburg, Germany; Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Harlachingerstraße 51, 81547 Munich, Germany
| | - Niklas Iblher
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Hugstetterstrasse 55, 79106 Freiburg, Germany; Center of Foot and Ankle Surgery, Schön Klinik München Harlaching, Harlachingerstraße 51, 81547 Munich, Germany
| | - Norbert P Südkamp
- Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrasse 55, Germany
| | - Hagen Schmal
- Department of Orthopedic and Trauma Surgery, University Medical Center, Hugstetterstrasse 55, Germany; Department of Orthopedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, 500 Odense C, Denmark
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Affiliation(s)
- Patrick K Strotman
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Taylor J Reif
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
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Kucera T, Shaikh HH, Sponer P. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. J Diabetes Res 2016; 2016:3207043. [PMID: 27656656 PMCID: PMC5021483 DOI: 10.1155/2016/3207043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022] Open
Abstract
Charcot neuropathic osteoarthropathy of the foot is a relatively common complication of diabetic neuropathy. Incorrect diagnosis and improper treatment often result in the extremity having to be amputated. This paper summarises the current view on the etiology, diagnostics, and treatment of diabetic Charcot neuropathic osteoarthropathy, with particular focus on preserving the extremity through surgical intervention from our own experiences.
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Affiliation(s)
- Tomas Kucera
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
| | - Haroun Hassan Shaikh
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Pavel Sponer
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
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30
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Lee DJ, Schaffer J, Chen T, Oh I. Internal Versus External Fixation of Charcot Midfoot Deformity Realignment. Orthopedics 2016; 39:e595-601. [PMID: 27280625 DOI: 10.3928/01477447-20160526-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 02/25/2015] [Indexed: 02/03/2023]
Abstract
Internal and external fixation techniques have been described for realignment and arthrodesis of Charcot midfoot deformity. There currently is no consensus on the optimal method of surgical reconstruction. This systematic review compared the clinical results of surgical realignment with internal and external fixation, specifically in regard to return to functional ambulation, ulcer occurrence, nonunion, extremity amputation, unplanned further surgery, deep infection, wound healing problems, peri- or intraoperative fractures, and total cases with any complication. A search of multiple databases for all relevant articles published from January 1, 1990, to March 22, 2014, was performed. A logistic regression model evaluated each of the outcomes and its association with the type of fixation method. The odds of returning to functional ambulation were 25% higher for internal fixation (odds ratio [OR], 1.259). Internal fixation had a 42% reduced rate of ulcer occurrence (OR, 0.578). External fixation was 8 times more likely to develop radiographic nonunion than internal fixation (OR, 8.2). Internal fixation resulted in a 1.5-fold increase in extremity amputation (OR, 1.488), a 2-fold increase in deep infection (OR, 2.068), a 3.4-fold increase in wound healing complications (OR, 3.405), and a 1.5-fold increase in the total number of cases experiencing any complication (OR, 1.525). This was associated with a 20% increase in the need for unplanned further surgery with internal fixation (OR, 1.221). Although internal fixation may decrease the risk of nonunion and increase return to functional ambulation, it had a higher rate of overall complications than external fixation for realignment and arthrodesis of Charcot midfoot deformity. [Orthopedics. 2016; 39(4):e595-e601.].
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Richter M, Mittlmeier T, Rammelt S, Agren PH, Hahn S, Eschler A. Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction - Results from a multi-centre study. Foot Ankle Surg 2015; 21:269-76. [PMID: 26564730 DOI: 10.1016/j.fas.2015.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 02/02/2015] [Accepted: 02/27/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Charcot osteo-neuroarthropathy (CN) of the foot can induce severe instability and deformity. Results of a consecutive clinical multi-centre study with Midfoot Fusion Bolt (MFB, Synthes GmbH, Oberdorf, Switzerland) are reported. METHODS All patients (aged 18 years and older) treated between 2009 and 2013 with surgical reconstruction of the midfoot with MFB for CN were included. Demographics, pre-surgical health status, details of foot pathology, details of surgery, postoperative treatment, treatment failure, and adverse events were registered. The following radiographic angles were measured on pre-op, post-op and last follow-up radiographs: talo-1st metatarsal (TMT) angle dorsoplantar and lateral view, and calcaneo-5th metatarsal angle. RESULTS Forty-seven patients (48 feet) were included in three centres. In 38 patients (80.1%) diabetes was diagnosed. Wound healing problems occurred in 21% of patients and recurrent ulceration in 13%. Revision surgery for loss of correction was performed in three cases (6%). Union rate at final follow-up was 98%. Major amputation for deep infection was performed in two patients (4%), minor amputation at the foot level in three cases (6%). Failure was more frequent when only one MFB (instead of 2 or 3) was used and no Gastrocnemius lengthening was performed. Radiographic alignment significantly improved pre- versus postoperatively and preoperatively versus follow-up. CONCLUSIONS Realignment and fixation with MFB in severe CN result in adequate correction with minimal loss of correction in the observed clinical course. The non-union rate was lower than previously reported. Stable fixation with MFB is a valuable treatment option for CN with minimal loss of correction and high union rates. The use of a minimum of two bolts is recommended to avoid recurrent deformity. Clinical Trials.gov: NCT01770639.
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Affiliation(s)
- Martinus Richter
- Department for Foot and Ankle Surgery, Sana Hospital Rummelsberg and Nuremberg, Germany.
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Germany
| | - Stefan Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Per-Henrik Agren
- Stockholms Fotkirurgklinik, Queen Sophia Hospital, Stockholm, Sweden
| | - Sarah Hahn
- Department for Foot and Ankle Surgery, Sana Hospital Rummelsberg and Nuremberg, Germany
| | - Anica Eschler
- Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Germany
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Matsumoto T, Parekh SG. Midtarsal Reconstructive Arthrodesis Using a Multi-Axial Correction Fixator in Charcot Midfoot Arthropathy. Foot Ankle Spec 2015; 8:472-8. [PMID: 26123549 DOI: 10.1177/1938640015592835] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
UNLABELLED Reconstructive surgeries for Charcot foot are challenging due to complicated conditions and comorbidities including poor bone quality, sensory abnormalities, poor vascularity, and immunity impairment. Although various fixation devices, including screws, plates, and external fixators, have been used in the surgical reconstruction of the Charcot midfoot, all of these devices are associated with some disadvantages. This study aims to evaluate the outcome of the Multi-Axial Correction (MAC) monolateral external fixation system for the reconstructive surgery of midfoot Charcot neuroarthropathy. A total of 11 feet with midfoot Charcot arthropathy were treated surgically using the MAC fixation system solely or accompanied with minimal internal fixation. The mean postoperative follow-up was 29 (range = 12-44) months. The mean postoperative timing of the MAC system removal was 8.7 (range = 5-14) weeks. No pin tract infections were observed. All patients went on to successful union and correction of a rocker bottom deformity. No cases resulted in limb amputation. All patients were able to ambulate with custom diabetic shoes and insoles in 9 patients (10 feet) and commercially available shoes in 1 patient (1 foot). This study suggests that the MAC system can be an acceptable, easy option for the surgical treatment of midfoot Charcot arthropathy. LEVEL OF EVIDENCE Therapeutic, Level IV: Case series.
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Affiliation(s)
- Takumi Matsumoto
- North Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina (TM, SGP)Duke Fuqua School of Business, Durham, North Carolina (SGP)
| | - Selene G Parekh
- North Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina (TM, SGP)Duke Fuqua School of Business, Durham, North Carolina (SGP)
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Eschler A, Gradl G, Wussow A, Mittlmeier T. Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score. BMC Musculoskelet Disord 2015; 16:349. [PMID: 26573860 PMCID: PMC4647281 DOI: 10.1186/s12891-015-0809-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/07/2015] [Indexed: 01/30/2023] Open
Abstract
Background All diabetic neuroosteoarthropathy (Charcot arthropathy) treatment concepts are focused on a long-term infection-free, ulcer-free, and plantigrade sufficiently stable foot in order to avoid amputation. Reconstructive arthrodesis techniques for severe deformities are associated with high postoperative complication rates. This study reports a detailed complication analysis and provides a strategy that may help detect patients at risk for a complicated postoperative course. Methods The study comprised 43 feet in 37 patients with severe non-plantigrade or unstable Charcot deformity, Eichenholtz stages II/III (Sanders and Frykberg types II-V), who underwent reconstructive arthrodesis of the mid- and/or hindfoot. Patients were retrospectively enrolled 4.5 years postoperatively (range 1.8–11.2 years). All patients showed at least two out of five positive Pinzur high-risk criteria (immuno-compromising illnesses, large bone deformity, longstanding ulcer overlying infected bone, regional osteopenia, obesity). Follow-up included a detailed clinical analysis and radiologic assessment with emphasis on complication analysis and evaluation in accordance to the PEDIS classification system. Results Significantly lower overall complication rates, as well as re-operation, reulceration and amputation counts were found for patients with a cumulative PEDIS count below 7. For PEDIS single criteria, significantly lower overall complication rates were found for patients without signs of occlusive peripheral artery disease, an ulcer extent <0.9 cm2, ulcer depth including erosion and inflammation of the skin and subcutaneous tissues only. Soft-tissue complications affected 49 % of patients, hardware breakage 33 %, hardware loosening 19 %, non-union 18 % and amputation 21 %. Radiographs revealed a correct reconstruction and restoration of all foot axes postoperatively with partial recollapse at the lateral foot column; however, fixation strength for the medial column was maintained. Conclusions Internal corrective arthrodesis for patients within the deformed stages of Charcot deformity can provide adequate reconstruction, as assessed by intraoperative radiographic measures, that exhibit superior long-term stability for the medial column. Despite a high risk patient population, a favourable outcome in terms of overall complication, re-ulceration, and amputation rates for patients/feet with a cumulative PEDIS count below 7 was found. The cut-off value of 7 may aid clinical decision-making during preoperative planning for Charcot deformity.
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Affiliation(s)
- Anica Eschler
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057, Rostock, Germany.
| | - Georg Gradl
- Department of Trauma, Orthopedic and Reconstructive Surgery, Klinikum München Harlaching, Sanatoriumsplatz 2, D-81545, Munich, Germany.
| | - Annekatrin Wussow
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock, Medical Center, Schillingallee 35, D-18057, Rostock, Germany.
| | - Thomas Mittlmeier
- Department of Trauma, Orthopedic and Reconstructive Surgery, Klinikum München Harlaching, Sanatoriumsplatz 2, D-81545, Munich, Germany.
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Butt DA, Hester T, Bilal A, Edmonds M, Kavarthapu V. The medial column Synthes Midfoot Fusion Bolt is associated with unacceptable rates of failure in corrective fusion for Charcot deformity: Results from a consecutive case series. Bone Joint J 2015; 97-B:809-13. [PMID: 26033061 DOI: 10.1302/0301-620x.97b6.34844] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°). However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot. In its present form, we cannot recommend the routine use of this bolt.
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Affiliation(s)
- D A Butt
- King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - T Hester
- King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - A Bilal
- King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - M Edmonds
- King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - V Kavarthapu
- King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Mittlmeier T, Eschler A. [Corrective arthrodesis of midfoot Charcot neuroosteoarthropathy with internal fixation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:139-53. [PMID: 25862129 DOI: 10.1007/s00064-014-0338-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/09/2015] [Accepted: 02/22/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The goal of treatment is a plantigrade, stable, ulcer-free foot which can be addressed with diabetes-adapted insoles and/or DNOAP shoes. INDICATIONS Charcot foot of the midfoot with/without infection-free ulcers. CONTRAINDICATIONS Inacceptable anesthesiological risk in polymorbidity. Severe anesthesiological risks in multimorbid patients; symptomatic peripheral arterial occlusive disease not suitable for reconstruction; infections PEDIS/IWGDF grade 3 or 4, nonreconstructable osseous defects. SURGICAL TECHNIQUE Corrective arthrodesis with segmental resection or bone grafting of the midfoot to achieve a plantigrade foot position. Plantar plate application or intramedullary (e.g., midfoot fusion bolt) and extramedullary (preferably: angular stable locking plates) implant combinations to create the highest possible degree of primary stability of the medial and/or lateral foot columns (superconstruct). In case of higher degrees of instability, the hindfoot should also be included into the arthrodesis. POSTOPERATIVE MANAGEMENT Partial weight-bearing (20 kg) with forearm crutches for 3-5 months postoperatively in special orthosis or total contact cast. Therapeutic shoes with diabetes-adapted insoles with full weight-bearing. RESULTS Using any of these stabilization variants, a plantigrade, stable, and long-lasting ulcer-free foot may be obtained that is suitable for custom-made footwear. The outcome does not depend on definite osseous healing of the arthrodesis and allows for the patient to have a self-determined lifestyle. The consecutive rate of amputation is low. COMPLICATIONS High rate of surgical complications (e.g., infection, implant failure, non-union, loss of correction, reulceration), in particular, in cases of inadequate indication or insufficient primary stability.
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Affiliation(s)
- T Mittlmeier
- Chirurgische Klinik und Poliklinik, Abt. für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18055, Rostock, Deutschland,
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Eschler A, Gradl G, Wussow A, Mittlmeier T. Late corrective arthrodesis in nonplantigrade diabetic charcot midfoot disease is associated with high complication and reoperation rates. J Diabetes Res 2015; 2015:246792. [PMID: 26000309 PMCID: PMC4427061 DOI: 10.1155/2015/246792] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 04/02/2015] [Accepted: 04/09/2015] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Charcot arthropathy may lead to a loss of osteoligamentous foot architecture and consequently loss of the plantigrade alignment. In this series of patients a technique of internal corrective arthrodesis with maximum fixation strength was provided in order to lower complication rates. MATERIALS/METHODS 21 feet with severe nonplantigrade diabetic Charcot deformity Eichenholtz stages II/III (Sanders/Frykberg II/III/IV) and reconstructive arthrodesis with medial and additional lateral column support were retrospectively enrolled. Follow-up averaged 4.0 years and included a clinical (AOFAS score/PSS), radiological, and complication analysis. RESULTS A mean of 2.4 complications/foot occurred, of which 1.5/foot had to be solved surgically. 76% of feet suffered from soft tissue complications; 43% suffered hardware-associated complications. Feet with only 2 out of 5 high risk criteria according to Pinzur showed significantly lower complication counts. Radiographs revealed a correct restoration of all foot axes postoperatively with superior fixation strength medially. CONCLUSION Late corrective arthrodesis with medial and lateral column stabilization in the nonplantigrade stages of neuroosteoarthropathy can provide reasonable reconstruction of the foot alignment. Nonetheless, overall complication/reoperation rates were high. With separation into low/high risk criteria a helpful guide in treatment choice is provided. This trial is registered with German Clinical Trials Register (DRKS) under number DRKS00007537.
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Affiliation(s)
- Anica Eschler
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
- *Anica Eschler:
| | - Georg Gradl
- Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Harlaching Clinic, Sanatoriumsplatz 2, 81545 Munich, Germany
| | - Annekatrin Wussow
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, University of Rostock Medical Center, Schillingallee 35, 18057 Rostock, Germany
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Wurm M, Schuh R, Wanivenhaus A, Windhager R, Trnka HJ. [The Midfoot Fusion Bolt: a new perspective?]. DER ORTHOPADE 2014; 44:65-70. [PMID: 25527299 DOI: 10.1007/s00132-014-3057-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is no current guideline nor consensus regarding optimal surgical treatment of the midfoot Charcot. Due to the vast diversity of locations, it is difficult to make a general statement. Various different types of screws and plates are currently being used since they have been tested and declared to be most stable. The Midfoot Fusion Bolt is a new device which needs approval since long-term results are lacking. A short summary of currently published papers and results from our own institution are provided. OBJECTIVES The aim of this study was to investigate short-term results including complications and review published surveys. METHODS The Midfoot Fusion Bolt is a solid, intramedullary screw. An antegrade as well as a retrograde technique are postulated for insertion. A total of 16 patients/17 feet in two specialized foot and ankle centers were included. BMI, HbA1c, satisfaction rates, complication rates, and expert opinions were recorded. RESULTS The bolts were used an average of 21.17 months (range 3-55 months) in 16 patients/17 feet. Between 2009 and 2014, six bolts had to be removed. We encountered 4 cases of postoperative ulceration: 2 cases healed postoperatively, while the other 2 cases led to amputation. The average fusion rate was 92.35 %. CONCLUSION The Midfoot Fusion Bolt is no longer advised for single-device use only since there have been issues in terms of insufficient stability. However, stable conditions could be achieved with additional screws or plates, respectively. Prospective studies and biomechanical testing for general conclusions are still required to make a meaningful assessment.
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Affiliation(s)
- M Wurm
- Allgemeines Krankenhaus Wien, Universitätsklinik für Orthopädie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich,
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